This section contains more-detailed information about High Deductible Plan with HSA's provisions and how this medical plan works.

You have a choice of using in-network providers or out-of-network providers. Using in-network providers saves you money in two ways. First, in-network providers charge special, negotiated rates, which are generally lower than the MAA. Second, the level of reimbursement for many services is higher when you use an in-network provider.

A directory of network providers is available directly from the Claims Administrator.

You must meet an annual deductible of $1,800 for individual (Employee Only) coverage or $3,600 for family (two or more in a family) coverage before the plan pays any benefits, unless the service is covered at 100%, such as preventive care.

The deductible applies to all covered expenses except preventive care and must be met each calendar year before any benefits will be paid. Whether you visit an in-network provider or an out-of-network provider, your costs count toward both deductibles.

Other than for services not subject to the deductible, any one or a combination of family members must meet the full family deductible before the plan pays any benefits. There is no individual limit within the family deductible limit. The deductible can be met as follows:

Your out-of-pocket maximum is $5,000 individual/$10,000 family (out-of-network $7,500/individual and $15,000/family). Each of your covered family members has an individual out-of-pocket maximum of only $6,850 for in-network coverage. After reaching that amount, your plan will cover 100% of that individual's in-network health care expenses for the rest of the year. The amount includes the $1,800/individual and $3,600/family (out-of-network $2,800/$5,600) deductible, coinsurance and any medical copays. This represents the most you will have to pay out of your own pocket in a calendar year.

Only your deductible, coinsurance amount and any applicable medical copays — not the amount billed over MAA by your doctor or facility — is applied to your out-of-pocket maximum. The maximum can be met as follows:

Once this out-of-pocket maximum is met, covered expenses are payable at 100% of the negotiated rate (or of MAA) for the remainder of the calendar year. However, the plan does not cover the amount over MAA. You can still be billed for that amount and are responsible for paying that portion.

Not all expenses count toward your out-of-pocket maximum. Among those that do not count are:

Out-of-pocket expenses cross-apply between in-network and out-of-network limits.

Covered expenses are not subject to the deductible and are covered at 100% when using in-network providers or 100% of MAA when using out-of-network providers.

Preventive care services include:

In addition, the plan will cover cancer-screening tests, well-adult immunizations and well-child care and immunizations at 100%. Cancer screenings are:

Preventive care services covered in the network at 100% will be reviewed annually and updated prospectively to comply with recommendations of the:

For more information on what is considered preventive care, see "Preventive Care."

Routine health screenings are covered at:

The annual deductible does not apply to routine care. However, routine care is subject to the following limits:

Aetna: Covered expenses include charges for an audiometric hearing exam if the exam is performed by:

To be sure your claim for a routine exam is paid properly, ask your physician to indicate "routine exam" on the bill. If a medical condition is diagnosed during a routine exam, your claim for a routine exam still will be paid as explained above, provided the bill is marked "routine exam."

After you meet your annual deductible, hospital care (inpatient and outpatient) will be reimbursed at:

Precertification of an inpatient admission is required. Precertification is also recommended for certain outpatient procedures and services.

Aetna: Precertification requirements apply to both inpatient care and partial hospitalizations.

After you meet your annual deductible, emergency care will be reimbursed at 80% for care received from both in-network and out-of-network providers.

Non-emergency services provided in an emergency room are not covered.

Aetna: When emergency care is necessary, please follow the guidelines below:

Urgent care centers will be reimbursed at:

Aetna: Call your PCP if you think you need urgent care. You may contact any physician or urgent care provider, in or out of network, for an urgent care condition if you cannot reach your physician. If it is not feasible to contact your physician, please do so as soon as possible after urgent care is provided. In-network providers are required to provide urgent care coverage 24 hours a day, including weekends and holidays. If you need help finding an urgent care provider, you may call Member Services at the toll-free number on your ID card, or you may access Aetna's online provider directory at www.aetna.com. Follow-up care is not considered an emergency or urgent condition and is not covered as part of any emergency or urgent care visit. Once you have been treated and discharged, you should contact your physician for any necessary follow-up care.

The Aetna/Anthem BlueCross BlueShield High Deductible Plan with HSA provides confidential mental health and substance abuse coverage through a network of participating counselors and specialized practitioners.

When you call the Claims Administrator at the telephone number on your ID card, you will be put in touch with an intake coordinator who will gather information from you and help find the right provider for you. In an emergency, the intake coordinator will also provide immediate assistance, and, if necessary, arrange for treatment in an appropriate facility.

You must call before seeking treatment for mental health or substance abuse treatment.

Mental health and substance abuse treatment benefits are subject to the same medical necessity requirements, coverage limitations and deductibles that are required under the High Deductible Plan with HSA.

Mental health benefits include, but are not limited to:

No benefit will be paid for services that are not considered to be medically necessary.

Aetna: In addition to meeting all other conditions for coverage, the treatment must meet the following criteria:

Benefits are payable for charges incurred in a hospital, psychiatric hospital, residential treatment facility or behavioral health provider's office.

You must call the Claims Administrator to give notification of inpatient services. Inpatient services are covered only if they are determined to be medically necessary and there is no less intensive or more appropriate level of care possible in lieu of an inpatient hospital stay. After you meet your deductible, inpatient stays are covered at 80% of the negotiated rate when you use an in-network provider or 60% of MAA if you use an out-of-network provider. If it is determined that a less intensive or more appropriate level of treatment could have been given, no benefits will be payable.

Generally, inpatient services must be rendered in the state in which the patient resides, unless approved by the Claims Administrator in advance of the admission.

Aetna: Benefits are payable for charges incurred in a hospital, psychiatric hospital or residential treatment facility. Covered expenses include charges for room and board at the semiprivate room rate, and other services and supplies. Inpatient benefits are payable only if your condition requires services that are only available in an inpatient setting. Covered expenses also include charges made for partial confinement treatment provided in a facility or program for the intermediate short-term or medically directed intensive treatment of a mental disorder. Such benefits are payable if your condition requires services that are only available in a partial confinement treatment setting.

You are encouraged to call the Claims Administrator for outpatient referrals. If you call and use the recommended provider, you will be reimbursed at 80% of covered expenses after the deductible is met. If you do not use an in-network provider, you will be reimbursed at 60% of MAA for covered services after the deductible is met.

Aetna: Covered expenses include charges for treatment received while not confined as a full-time inpatient in a hospital, psychiatric hospital or residential treatment facility. The plan covers partial hospitalization services (more than four hours, but less than 24 hours per day) provided in a facility or program for the intermediate short-term or medically directed intensive treatment. The partial hospitalization will only be covered if you would need inpatient care if you were not admitted to this type of facility.

Emergency care for mental health or substance abuse treatment does not require a referral. However, you are encouraged to call the Claims Administrator within 48 hours after an emergency admission. The behavioral health provider is available 24/7 to accept calls.

The Claims Administrator will help you and your physician determine the best course of treatment based on your diagnosis and acceptable medical practice. The Claims Administrator will determine whether certain covered services and supplies are medically necessary solely for purposes of determining what the medical plans will reimburse. No benefits are payable unless the Claims Administrator determines that the covered services and supplies are medically necessary. See the Glossary section for the definition of medical necessity.

For more information about what your plan covers, see "Covered Services and Supplies." You may also contact your plan directly to confirm coverage of a particular service or supply and to find out what limits may apply.